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The Every Day Blues Battle—DYSTHYMIA

While dysthymia may have fewer symptoms, and perhaps with less severity than major depressive disorder (MDD), this chronic and serious condition remains difficult to diagnose.

By Robin L. Flanigan

It seemed as if the whole town had come to the same neighborhood party. People danced to a live band, kids had their faces painted, dogs ran freely.

Dan, who lives in Massachusetts, had come to the party with his wife and her parents while visiting his in-laws in Maryland.

On the surface everything seemed great.

“It was such a beautiful day and everyone seemed happy,” he recalls.

But he couldn’t relate.

“There was no reason for me to be sad, but I wasn’t happy,” he says. “I put on a reasonably pleasant front, but was aware that this wasn’t a place I wanted to be.”

For years, he had been in a place of chronic depression—able to function but racked with a melancholy that was affecting his relationship with his wife and two children.

Dan has persistent depressive disorder, now the official diagnosis for what used to be known as dysthymia. The diagnosis is given when a low mood state “most of the day, for more days than not,” lingers for two years or longer.

While major depressive disorder requires five of seven other criteria to be present, the bar for persistent depressive disorder is two symptoms from a list of six: lack of appetite or overeating, insomnia or overeating, low energy, low self-esteem, difficulty concentrating or making decisions, and feelings of hopelessness.

That’s part of the reason many people don’t seek treatment for years, if at all. When something is so constant, it easily takes on an air of normalcy—an insidious presence that can favor a hopeless worldview that no change in partners, jobs or neighborhoods can fix.

“It’s not as bad as with other kinds of depression, where it really shuts you down,” says Megan Gunnell, a psychotherapist in Grosse Pointe, Michigan. “It’s just this gloomy Eeyore kind of feeling, without the pockets of sunshine that people who don’t have dysthymia have.

“And often there’s this lens like, ‘I guess these are the cards I’ve been dealt,’” she adds. “But you don’t have to just survive your life. It can be so much more pleasant and joyful and meaningful.”

Through therapy, Dan explored why he’d been wrestling for decades with “automatic negative thinking and a lot of self-doubt from long-standing anger issues,” both of which stem from being a perfectionist and overly sensitive to criticism.

He also found help through Families for Depression Awareness, a national organization that educates families on how one person’s depression affects others—like his wife, who had to put up with his temper, and subsequent withdrawal from shame, after expressing a concern about his mood or behavior.

It has been about eight years since Dan has felt the need to be in therapy, although he still sends his therapist Christmas cards to report how he’s doing.

“That has been important to me,” he says, “knowing that going back is an option if I ever need it.”

CHALLENGING TO DETECT

Like major depression, dysthymia is more common in women than in men.

Because dysthymia can be challenging to detect, it doesn’t get as much attention as major depressive disorder or anxiety disorders, according to Karen G. Martinez, MD, a researcher and assistant professor of psychiatry at the University of Puerto Rico.

“When symptoms are so chronic, people might not even notice something is going on,” she says.

Complicating matters further, she adds, is that the formal definition in the DSM-V—the current edition of the Diagnostic and Statistical Manual of Mental Disorders, the mental health profession’s standard reference—represents a consolidation of what used to be separate definitions of chronic major depressive disorder and dysthymic disorder.

“We need to do more research,” says Martinez, a member of the Anxiety and Depression Association of America, “especially since most patients with persistent depressive disorder start in adolescence.”

Data from the National Institute of Mental Health shows that dysthymia and major depressive disorder together affect approximately 11.2 percent of 13- to 18-year-olds in the United States at some point in their lives. Youth are diagnosed with dysthymia after one year of symptoms, which tend to present more as irritability or anger.

Because dysthymia tends to exist along with other mental health disorders, resulting in extended periods of sadness, it can be easy to believe that present circumstances are unlikely to change. But one 2017 study, out of Athabasca University in Canada, has found that an integrative approach to psychotherapy—one that combines components of cognitive, behavioral, interpersonal and psychodynamic therapies—is an effective treatment for dysthymia.

Karen, from Las Vegas, Nevada, was diagnosed with dysthymia in 2000. While also experiencing anxiety and obsessive-compulsive disorder, the dysthymia diagnosis gave her the sense of agency she had been searching for since high school.

“It was always like I was moving in a fog, this sense that I was watching things from a distance and nothing really mattered,” she remembers. “I knew it wasn’t right, but I’d felt that way for so long that I just sort of went along with it. Learning that this was an actual condition and something that was manageable helped me to love the parts of me that are sensitive and emotional—the parts I thought needed to be fixed. It freed me up to be myself.”

Even so, Karen admits that she still has a tendency to doubt herself, even catastrophize situations.

“I do find it hard not to compare myself to other people and tell myself I should be doing more, trying harder, achieving more,” she says. “But then another part of me says ‘This is who I am and this is where I am.’ And it doesn’t do any good to critique that.”

Although antidepressants generally aren’t as effective for dysthymia as with more major depressive disorder, they can offer some relief—which they do for Karen, who also sees her therapist when she feels the need.

Medication has been found to be particularly beneficial when paired with psychotherapy.

CHANGING AN UNSATISFIED LIFE

In her work with dysthymia-related concerns, Lilia Berkovich, a licensed clinical psychologist in Chicago, sometimes points out patterns that keep people stuck in unfulfilling relationships.

She advises asking a few questions: What am I attracting for myself? What am I looking for in the world? How can I get my needs met?

“It helps to not point fingers as to who is the problem, but to ask why it is that you’re finding yourself in situations where the bottom line is you’re unsatisfied,” she says.

And prolonged unsatisfaction of any kind can lead to self-medication in search of comfort.

Drug and alcohol use is not uncommon with dysthymia, according to Harvard Medical School, which cites that at least three-quarters of patients with the condition also have a drug or alcohol addiction, a chronic physical illness, or other psychiatric disorder.

Christopher from Newton, Massachusetts, can relate.

“I was never somebody who woke up and said, ‘It’s going to be a good day today,’” he says. “My default was, ‘Everything sucks. What can I do to feel better?’ It was all a distraction from what the real problems were.”

Christopher believes his dysthymia, diagnosed in 2009, came from growing up in a family with a long history of mental health challenges and substance abuse.

“I got accustomed to a life that was steeped in drama and intimidation, sometimes violence,” he says. “Later on with my intimate relationships, I ended up gravitating toward people who were volatile and unpredictable and risky.”

That pattern continued until he met his current wife; they married in 2012.

Aside from running between 18 and 20 miles a week to help elevate his mood, Christopher says regular therapy appointments have helped him keep his confrontational habits and temper in check.

“My new therapist lets me off the hook on nothing,” he says. “We’ve been able to tear into some very uncomfortable things, but now I can say that on a daily basis I do a much better job of being aware of my triggers.”

‘BEING VULNERABLE AND TAKING RISKS’

Becoming aware of certain triggers can come from breathing techniques and other exercises—“any sort of movement to help a person understand this is something they have control over and can shift over time,” says Sudha Rani Kailas, MD, PhD, a psychiatrist in Santa Fe, New Mexico.

When struggling with a chronic illness, it can be easy to stop visualizing goals and dreams for the future. Kailas helps patients stay the course by reminding them what we all do, or have done, in school—review and study information to do well on the test.

“It’s a good metaphor for life,” she says. “If we don’t examine our lives and ask for what we want—if we don’t keep our hearts open as much as possible—then it will be very difficult for that moment to show up for us.”

Gunnell, the Michigan psychotherapist, uses multiple techniques to help patients break out of a sad, low or dark mood—particularly those who use “denial disclaimers” to explain away their need for assistance, such as “Well, I can still go to work” or “I’m not crying all the time.”

“It’s complex, but sometimes the justification for staying in that mood is because they feel like they’re in a cozy sweater,” she says, “and being comfortable there keeps them from having to make deep connections with people, of being vulnerable and taking risks.”

Gunnell uses cognitive behavioral therapy—the most effective psychotherapy treatment for depression—to put thoughts and feelings into two columns. One column holds fears, worry, distortions; the other column holds facts. For example, it someone hasn’t returned a phone call, the first column may include feelings of rejection and anger. But what if that person just had a baby and may be really busy? Oftentimes, there is lots of evidence to counter negative assumptions.

She also uses acceptance and commitment therapy, based in mindfulness, to help people develop a more compassionate relationship with unwanted thoughts and feelings.

Those unwanted thoughts and feelings are going to come—because we’re human—but they don’t have to leave us feeling trapped or victimized.

“I like to give people psychological flexibility—a way to move out of this track of rigidity that makes them think this is the only way to show up in the world,” says Gunnell. “They can become empowered. They can change.”

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Beating the Blues

Dysthymia makes every day feel a bit off—and can lead to low self-esteem, neglected opportunities, and less-than-meaningful relationships. But there are ways to manifest a brighter outlook, one that creates actual change that can seem out of reach when in a perpetual funk. Here are some tips for breaking out of the blue zone:

Elevate your mood. Become more physically active. Sleep more and eat better. Think about what social opportunities interest you—then seek them out. “These things are basic and easy to overlook,” says Lilia Berkovich, a licensed clinical psychologist in Chicago. “But they are very important.”

Be mindful. “When we can stop thinking about the past and being preoccupied about the future, we’re able to bring more joy to the moment in front of us,” says psychotherapist Megan Gunnell.

Practice self-care. Try mangoes or tart cherries for a good night’s sleep, or a bath with mineral-packed sea salts to promote relaxation, detoxification and other benefits, suggests psychiatrist Sudha Rani Kailas. “Even a foot bath can be very helpful in relaxing the nervous system,” she says.

Commit to seeking help. Christopher, from Massachusetts, knows people who’ve given up on therapy after one session. “If the first encounter doesn’t seem to help, don’t discard the whole process,” he says. “Maybe the therapist wasn’t right for you. But you also have to put in the time and work yourself.” (A mental health professional can also talk with you about whether antidepressants may offer some relief.)

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Dysthymia: The Overlooked Depression

Persistent Depressive Disorder, often referred to simply as dysthymia, is essentially chronic depression that has lasted two or more years in adults (at least one year in youth, for whom it presents more as irritability or anger).

The formal definition in the DSM-5 (the current edition of the Diagnostic and Statistical Manual of Mental Disorders, the mental health profession’s standard reference) includes having at least two depressive symptoms—such as sleep-, appetite-, or self-esteem issues—for most of the day for most days. Acute or major depression typically would involve a greater number of symptoms.

Though dysthymia is a chronic low-grade depression compared to acute or major depression, “the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

According to the U.S. National Institute of Mental Health, at any given time about 1.5 percent of the adult population will be experiencing dysthymic disorder. Harvard Medical School reports that more than half of people with dysthymia eventually have an episode of major depression, and about half of patients treated for major depression are suffering from this double depression.

2 COMMENTS

Karen

Dysthymia reeks havoc with self-esteem. Being around friends, family and/or colleagues who speak about being “excited” about an upcoming event or describe an outing as being “fun” and being totally unable to relate to those types of emotions, makes me feel “different” and “deficient.” It’s as if those good feelings—feelings of joy, are missing from my DNA! I am trying to institute almost all of the techniques, therapy, plus medication described in this article, yet everyday continues to be a struggle.

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HEALTHY HABITS

Most of us don’t default to healthy habits. It takes planning and effort, and sometimes a surge of self-discipline, to eat right, exercise, get the sleep we need, and stay on top of work and life tasks. Establishing new habits, let alone purging bad ones, can require major effort, especially if we are also struggling with depression or anxiety. What are some good habits that you've formed and how did you build them?